Analysis of Prescriptions for Dual Antiplatelet Therapy After Acute Ischemic Stroke
Authors: Ying Xian, Haolin Xu, Roland Matsouaka, Daniel T. Laskowitz, Lesley Maisch, Deidre Hannah, Eric E. Smith, Gregg C. Fonarow, Deepak L. Bhatt, Lee H. Schwamm, Brian Mac Grory, Wuwei Feng, Emil Loldrup Fosbøl, Eric D. Peterson, Mark Johnson
Journal: JAMA Network Open (2022)

After the publication of the CHANCE (Clopidogrel in High Risk Patients With Acute Nondisabling Cerebrovascular Events) and POINT (Platelet-Oriented Inhibition in New Transient Ischemic Attack and Minor Ischemic Stroke) clinical trials, the American Heart Association/American Stroke Association (AHA/ASA) issued a new class 1, level of evidence A, recommendation for dual antiplatelet therapy (DAPT; aspirin plus clopidogrel) for secondary prevention in patients with minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score Յ3).The extent to which variations in DAPT prescribing patterns remain and the extent to which practice patterns in the US are consistent with evidence-based guidelines are unknown.OBJECTIVE To evaluate the discharge DAPT prescribing patterns after publication of the new AHA/ASA guidelines and assess the extent of hospital-level variation in the use of DAPT for secondary prevention in patients with minor stroke (NIHSS score Յ3), as indicated by guidelines, and in patients with nonminor stroke (NIHSS score >3), for whom the risks and benefits of DAPT have not been fully established.DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study involved 132 817 patients from 1890 hospitals participating in the AHA/ASA Get With The Guidelines-Stroke program.Patients who were hospitalized for acute ischemic stroke and prescribed antiplatelet therapy at discharge between October 1, 2019, and June 30, 2020, were included.EXPOSURES Minor ischemic stroke (NIHSS score Յ3) vs nonminor ischemic stroke (NIHSS score >3). MAIN OUTCOMES AND MEASURESThe primary outcome was DAPT prescription at discharge.The extent to which variations in DAPT use were explained at the hospital level was assessed by calculating the median odds ratio (OR), which was derived using multivariable logistic regression analysis and compared the likelihood that 2 patients with identical clinical features admitted to 2 randomly selected hospitals (1 with higher propensity and 1 with lower propensity for DAPT use) would receive DAPT at discharge.Associations between hospital-level DAPT use among patients with minor vs nonminor stroke were evaluated using Pearson ρ correlation coefficients. RESULTSAmong 132 817 patients (median [IQR] age, 68 [59-78] years; 68 768 men [51.8%]), 4282 (3.2%) were Asian, 11 254 (8.5%) were Hispanic, 27 221 (20.5%) were non-Hispanic Black, 84 468 (63.6%) were non-Hispanic White, and 5592 (4.2%) were of other races and/or ethnicities (including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and unable to determine).Overall, 86 551 patients (65.2%) presented with minor ischemic stroke, and 46 266 patients (34.8%) presented with nonminor ischemic stroke.After the 2019 AHA/ASA guideline updates, 40 661 patients (47.0%) with minor stroke (NIHSS median [IQR] score, 1 [0-2]) and 19 703 patients (42.6%) (continued) Key Points Question Have prescribing patterns in dual antiplatelet therapy (DAPT) for secondary prevention among patients with acute ischemic stroke changed after clinical trial findings and American Heart Association/American Stroke Association practice guideline updates?Findings In this cohort study of 132 817 patients with acute ischemic stroke, 47.0% of patients with minor stroke received DAPT at discharge, as indicated by guidelines; 42.6% patients with nonminor stroke, for whom the risks and benefits of DAPT have not been fully established, received DAPT at discharge, with substantial hospital variation across current US practice.Meaning This study's findings suggest that enhancing adherence to evidencebased DAPT practice guidelines may be a target for quality improvement in the treatment of patients with ischemic stroke.